EUROPEAN COMMISSION - JOINT RESEARCH CENTRE Institute for the Protection and Security of the Citizen...

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EUROPEAN COMMISSION - JOINT RESEARCH CENTREInstitute for the Protection and Security of the CitizenHazard Assessment Unit

P.C. Cacciabue

Humar Error Consideration in Modern Technology and Risk

Assessemnt

COLLOQUE 10ème ANNIVERSAIRE LAMIH

Valenciennes, 23 mars 2005

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1. Methodological approach to Human Factors

analysis

2. Focus on area Risk Assessment and human

reliability methods

3. Ongoing actions at JRC in Human Factors

studies

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Savoir Faire of Sector HF :A technology for analysis and optimisation of the relationship between people and their activities at work, by the integration of human sciences and engineering.

Areas of Application :Design, Training, Safety Assessment & Accident Investigation

Domains of Application :

Transport (Aviation), Energy, Process systems

Customer :EC legislation and regulations

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Methodological approach to

Human Factors analysis

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Human Error is an unavoidable presence in everyday life

It is not conceivable a society that is “error free”

Human Error must be considered and dealt with in the design and assessment of any technological system

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Risk Management

To reduce Human ErrorHuman Error implies to deal with all types of errors, e.g., “slips”, “lapses”, “mistakes” e “violations”, especially those coming from organisations levels, also called latent errors by means of engineering measures that reinforce the technological response to errors/failures, as well as the implementation of non-technical means, e.g., training, procedures etc.

Human Error and Accident ManagementHuman Error and Accident Management (HEAMHEAM): the variety of methods for controlling HMI at risks by the implementation of means for early recognition and preventionprevention, their controlcontrol and recoveryrecovery from accidental situations and for the containment of the consequences.

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Adequate methods for HEAM allow an organisation to be constantly aware and informed of its state of “safety” and to evaluate and identify critical areas of concerns for safety by tests and audits that can be done in real time.

The starting point is the Architecture of Human-Machine Interaction (HMI)

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STANDPOI NT 3: Prospective and retrospective approaches

Commonality of reference models of HMI

Data and parameters: outcome of retrospective & input to prospective methods

STANDPOI NT 4: Areas of application

Design Training Accident investigation Safety Assessment

STANDPOI NT 2: Concept of “Human Machine System”

Models of Human Machine I nteractions, as events embedded & dependent on socio-technical context and dynamic contingencies

STANDPOI NT 5: Measure of safety levels

Safety critical indicators as guiding elements of safety assessment

Recurrent Safety Audit as means f or dynamic safety assessment

STANDPOI NT 1: Goals of “Human Machine System”

Goals of HEAM

Prevention of accidents Recovery f rom accidents Containment of consequences

Goals of UCD

Eff ectiveness Effi ciency Friendliness

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Goals of HMS

HEAM:• Prevention • Recovery • Containment

DESIGN:

• Superv. Control

• UCD

• Usability

HEAM:• Prevention • Recovery • Containment

DESIGN:

• Superv. Control

• UCD

• Usability

SP1

• Model of HMS• User Feedback

• Manual control• Supervisory cont. • Full automation

• Effectiveness• Efficiency • Satisfaction

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SP2

Un

der

stan

din

g:

• h

um

an p

erfo

rman

ces

• d

epen

den

ce o

n d

ynam

ic c

on

text

•

soci

o-t

ech

nic

al e

nvi

ron

men

t

H u m i d i t y / h e a t

N a t i o n a l c u l t u r e

C o m p a n y r u l e s

T e a m W o r k

C o m m u n i c a t i o n s

C o n t e x t S t i m u l i

H u m a n R e s p o n s e s

P l a n t S t i m u l i

O N

O F F

0 1

t / h X

Interfaces

0

Interfaces 1 d e s

c en d t o

2 2 0 3

4 w

1 d e s

c en d t o

2 2 0 3

4 w

0

Interfa

2 3 7 - w

I n t er f a ce s 1 d e s c e n d t o 2 2 0 3 4 w

1 d e s c e n d t o 2 2 0 3 4 w

0


1 d e s c e n d t o 2 2 0 3 4 w

0


1 d e s c e n d t o 2 2 0 3 4 w

0


1 d e s c e n d t o 2 2 0 3 4 w

C o n t r o l s

N o i s e , W e a t h e r , . .

v o i d

0 1

t / h

P a

m

I n t e r f a c e s

C o n t e x t / E n v i r o n m e n t

2 3 5 @ 0 9 0 1 7 5 K h

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Elementi di Gestione dell’Errore Umano

Prospective Analysis

Retrospective Analysis

Evaluation of consequences

Creative thinking

Ethnographic Studies

Data & parameters

HF Theory & Model of HMI

Cognitive Task Analysis

Root Cause Analysis

I nitiating Events & Boundary Conditions

Typ

es o

f A

nal

ysis

SP3

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Data & Parameters

Audio- Video recording

Visits to workplaces

Observation at workplaces

I nterviews and questionnaires

Verbal/behavioural protocols



ETHNOGRAPHY

RETROSPECTIVE

ANALYSIS

Root Cause Analysis

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Are

as

of

Ap

plic

ati

on

Area of Application Type of Assessment

Design

Design of control, emergency & protection systems

Design of human-machine interfaces

Development of Normal and Emergency Procedures

Training Classroom Human Factors training

Human Factors training in simulators

Safety Assessment

Human contribution to Design Basis Accident

Human contribution to Probabilistic Risk Assessment

Evaluation of safety levels of an organisation by Recurrent Safety Audits

Accident Investigation Human contribution to real accident aetiology and

identification of root causes

SP4

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Ind

ica

tors

of

Sa

fety

Le

ve

ls

Organisational Processes

Local Working Conditions

Personal and External Factors

Defences, Barriers, Safeguards

Prospective Analysis

Retrospective Analysis


Creative thinking

Ethnographic Studies

Data & parameters



Root Cause Analysis

I nitiating Events & Boundary Conditions

Data & parameters

SP5

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Identification: Boundary conditions Initial conditions

Evaluation: Data, Influencing factors Erroneous behaviour

ACCIDENT/INCIDENT INVESTIGATION

Root Cause Analysis

Retrospective Analysis Prospective Analysis

Identification: Causes, effects, reasons Parameters, markers

TRAINING

DESIGN &

SAFETY ASSESSMENT

Evaluation: Consequences Hazards

EVALUATION OF SOCIO-TECHNICAL CONTEXT

Of RC Ethnographic Studies Cognitive Task Analysis

THEORETICAL STAND

Models and Taxonomies of HMI

H

um

an E

rro

r R

isk

Man

agem

ent

for

En

gin

eeri

ng

S

yste

ms

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Risk Assessment and Human Reliability

methods

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Maximum credible

accident Models, conservation

equations and parameters

Initial and boundary conditions

Numerical Methods and simulations

DETERMINISTIC SAFETY ASSESSEMNT

SAFETY ASSESSMENT

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SAFETY ASSESSMENT

Deterministic analysis

Sets of initiating events Probability of failures

Logical analysis of consequences

Probability of sequences and sets of events

Uncertainty assessment


QUANTITATIVE RISK ASSESSMENT

.

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SAFETY ASSESSMENT

Analysis of past

events Evaluation of current working conditions

Evaluation of safety requirements

Observation, questionnaires, interviews

SAFETY AUDIT

INDICATORS of safety

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Classical Human Reliability Approaches to Risk Assessment

SHARPSHARP

no

no ST E P 6Q U A N T IF IC A T IO N

yes

fur ther eva luation r equ ir ed

ST E P 5IM P A C T A SSE SSM E N T

ST E P 4R E P R E SE N T A T IO N

ST E P 3B R E A K D O W N

deta iled analysis r equ ir ed

yes ST E P 2SC R E E N IN G

ST E P 1D E F I N I T I O N

ST E P 7D O C U M E N T A T I O N

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EUROPEAN COMMISSION - JOINT RESEARCH CENTREInstitute for the Protection and Security of the CitizenHazard Assessment UnitTHERPTHERP

FA M IL IA R Z A T IO N

Plant Visit

Q U A L IT A T IV E A N A L Y S IS

Talk- or walk-through

T ask A n aly sis

A ssign n o m in al H EP s

Estim ate th e relativ e effects o f P SFs

D eterm in e th e eff. o f reco v ery actio n s

Estim ate th e P SFs

IN C O R PO R A T IO N

In clu sio n o f resu lts in P SA

Q U A N T IT A T IV E A N A L Y S IS

Sen sitiv ity A n aly sis

In fo rm atio n fro m sy stem an aly sts

A ssess d ep en d . an d ev alu ate p (S), p (f)

D ev elo p H R A Ev en t T rees

A

B /A

a

b/AB /ab/a

S F F

S S SFF

T ask 'A '

T ask B '

S eri es

P aral l el

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B = .002

C = .002

A = .006

D = .006

G ' = .503

J ' = .144J = .001

I = .01

G = .006

H = .001

E ' = .503E = .006

H = .001 H = .001 H = .001

G '' = .752

I ' = .505

a = .994

b = .998

c = .998

d = .994

e = .994

g = .994

h = .999

i = .99

j = .999

F 1 = .006

F 2 = .00199

F 3 = .00198

h = .999 h = .999 h = .999

i ' = .495

j ' = .856

F 8 = .00007

F 9 = .00989

F 10 = .000979S1 = .978 S2 = .000415

e' = .497

g' = .497 g'' = .248

Sg'' = .00074Sg' = .00293

Se' = .00295

Sh = .00587 Sh = .00297 Sh = .00225

Si = 0.9784

F i = 0.0216

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Critique of Classical HRA

are very superficial for what concerns the cognitive processes

only a few methods make some reference to the dynamic aspects of the human-machine and human-human interaction

Are completely focused on HRA/PSA reliability studies

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Modern Human Reliability Approaches

ATHEANAATHEANA

Plant DesignOperation andMaintenance

ErrorMechanisms

UnsafeActions

HumanFailureEvents

PerformanceShapingFactors

RiskManagement

Decisions

PlantConditions

ScenarioDefinition

ErrorForcingContext

HumanError

PRAModel

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COCOM-COCOM-CREAM-FAMECREAM-FAME

COCOM

Contextual Control Model

FAME

Function Allocation Method

CREAMCognitive Reliability andError Analysis Method

Generator of Sequences

Analysis HRA and HMISequences

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DYLAMDYLAM

Classification scheme

Field studies Question./interviews Expert judgement Accident analysis

Data/parameter

Model of cognition

Model of the plant

Model of dynamic reliability

Human Machine Interaction analyses

Initiating Events

DYLAM Prospective/retrospective studies

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DENDROS Implementation of the general methodology for Deterministic Dynamic Event Tree (DDET) generation

DAD REM An Integrated Approach to Human Reliability Analysis - Decision Analytic Dynamic Reliability Model

RECUPERARE Develop a better approach of pre-initiator errors and "human" initiators

OPSIM Simulation of the integrated operator-plant system and addresses the dynamics and interdependence of the plant and operator responses during accident sequences

TAFEI Task Analysis For Error Identification

PHECA Potential Human Error Causes Analysis

SHERPA Systematic Human Error Reduction and Prediction Approach

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CADA Critical Action and Decision Approach

HRMS Human Reliability Management System

HUMECA Human Error Mode Effects and Criticality Analysis

PREDICT Procedure to Review and Evaluate Dependency in Complex Technologies

CORE-DATA Computerised Operator Reliability and Error Data Base

DORRET Determination of Operator Recovery Reliability over Extended Time scales Human Error Causes Analysis

HEART Human Reliability Assessment Method

JHEDI Justification of Human Error Data Information

HEIST Human Error in Systems Identification Technique

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Indicators of Safety Levels

Organisational Processes

Local Working Conditions

Personal and External Factors


SAFETY AUDIT

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Organisational Processes (OP) Unconscious beliefs; Values; Norms; Fundamental assumptions; Unwritten rules; Etc….

Local Working Conditions (LWC) Workplace design; Automation; Tools and actuators; Protective equipment; Job planning; Etc……

Personal and External

Factors (PEF) Co-ordination ability; Physical characteristics; Mental conditions; System performance; Random system

contingencies; Etc…..

Defences, Barriers, Safeguards (DBS) Engineered safety devices; Protective equipment; Training; Policies, standards, control; Procedures, instructions,

supervision; Etc……

Ind

icat

ors

of

Saf

ety

Lev

els

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EUROPEAN COMMISSION - JOINT RESEARCH CENTREInstitute for the Protection and Security of the CitizenHazard Assessment UnitS

afet

y L

evel

s &

Mea

sure

s

Engineered safety devices

Protective equipment

Training

Policies, standards & control

Procedures, instructions and supervision

Prevention Recovery Protection

A0 β0 d0

S0 α0 l0

T0 μ0 t0

b0 ------- -------

V0 a0 ------- Engineered safety devices


Training




A1 β1 d1

S1 α1 l1

T1 μ1 t1

b1 ------- -------

V1 a1 -------

As resulting from original design


Vi

Ai

Si

Ti

βi

αi

μi

ai

di

li

ti

bi ------- -------

-------

Engineered safety devices


Training



Current safety state

As required by regulations and

standards


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Ongoing actions at JRC in Human Factors

studies

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COMPETITIVE COMPETITIVE ACTIVITYACTIVITY

AVIATION URBAN TRANSPORT

RAILWAY

AUTOMOTIVE CHEMICAL

BIOLOGICAL

RADIOLOGAL

V FWP

VI FWP AIDE

HUMANIST

RANKERS

EUCLIDE

MODURBANHILAS

UGTMSADAMS 2

ONBUS

INSTITUTIONAL ACTIVITYINSTITUTIONAL ACTIVITY ISARM

FAST

VIRTHUALIS

ASTER

IMPACT

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Aim of the action: To develop a body of guidelines for integrating safety assessment and risk management methods throughout the whole aviation system

Main topics:

•Detecting root causes in aviation accident investigation by applying Human Factors methods•Developing risk assessment and recurrent safety audits in civil aviation organisations. •Extension of Safety and Risk Assessment techniques to deal with Security problems in transportation

Directive 2003/42/EC of the EUROPEAN PARLIAMENT and of THE COUNCIL

on occurrence reporting in civil aviation (13 June 2003)

Directive 2003/42/EC of the EUROPEAN PARLIAMENT and of THE COUNCIL

on occurrence reporting in civil aviation (13 June 2003)

Institutional Activity 4.3.3.7 ISARMISARMISARMISARMIntegrated Safety Assessment and Integrated Safety Assessment and Risk ManagementRisk Management

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JAR 145.60JAR 145.60 (Occurrence reporting) : (Occurrence reporting) :

““(a) The JAR–145 approved (a) The JAR–145 approved maintenance organisationmaintenance organisation must report to its must report to its JAA full member AuthorityJAA full member Authority and the and the organisation responsible for the design of the organisation responsible for the design of the aircraft or aircraft component aircraft or aircraft component any condition of the any condition of the aircraft or aircraft component, aircraft or aircraft component, identifiedidentified by the JAR–145 by the JAR–145 approved maintenance organisation that has resulted or approved maintenance organisation that has resulted or may result in an unsafe conditionmay result in an unsafe condition that could that could seriously seriously hazardhazard the aircraft.” the aircraft.”““(d)(d) Where the JAR–145 approved maintenance Where the JAR–145 approved maintenance organisation is organisation is contracted by an operatorcontracted by an operator to carry out to carry out maintenance, the JAR–145 approved maintenance maintenance, the JAR–145 approved maintenance organisation organisation must also report to themust also report to the operatoroperator any such any such condition affecting the operator’s aircraft or aircraft condition affecting the operator’s aircraft or aircraft component.”component.”

Directive 2003/42/EC of the EUROPEAN PARLIAMENT and of THE COUNCIL on occurrence reporting in civil aviation (13 June 2003)

Directive 2003/42/EC of the EUROPEAN PARLIAMENT and of THE COUNCIL on occurrence reporting in civil aviation (13 June 2003)

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The Joint Aviation Authorities (JAA), Europe, and the Federal Aviation Administration (FAA), USA, sponsor a number of research groups aimed at improving aviation safety.

FAST aims at continuous improvements of effective safety systems leading to further reductions of the annual rate of accidents irrespective of the growth of the air traffic (5 % per year).

ISARMISARMISARMISARM Institutional Institutional ActivityActivity

FASTFASTFuture Aviation Safety TeamFuture Aviation Safety Team

The FAST group brings together experts from: EUROCONTROL, DG TREN, JRC, Group of Airport Safety Regulators (GASR), FAA, CAST, International Federation of Airworthiness (IFA), European Space Agency (ESA), NASA and ICAO.

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FUTURE AVIATION SAFETY TEAM

JSSI STGP

2001 2002 2003>>>>

#1

11

#2#3

J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D

#5

report

"10"areas ofchange

#4

2 areas of change

#6

future hazards, wholeprocess, incl. interventions,excl. monitoring of results

8 remaining areas

of changeinto > future hazards

#6

generic analysis schedule for areaof change > hazards >

interventions

#7

#8 #9 10 113 + 4

5

6+ start on

6 6

7

write report

note 1: numbers refer tomethodology - example chart

note 2: for 1 st 2 areas of changeFAST #6 (Sep 2001) thruFAST #11 (Sep 2002)

report: areas of change prioritized selected "10"

FAST meetings5 - 3 days meetings

1 meeting for report(3days)

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Areas of Change (AoC):Aircraft (AC); Maintenance, Repair & Overhaul (MRO) ; Operations (OP); Crew (C); Passenger (P); Organisation (O); Authority (AUTH); Air Navigation System (ANS); Airport (AP); Environment (E); Space Operations (S)

0

0,02

0,04

0,06

0,08

0,1

0,12

0,14

0,16

Aircraft Crew ANS Operations Maintenance Organization Authority Environment Airport Passengers Space

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Human Centred Systems for Aircraft Dispatch and Maintenance Safety

COMPETITIVE and SUSTAINABLE GROWTH PROGRAMME GRD1-2000-25751

PROJECT START: FEBRUARY 2001PROJECT END: MARCH 2004

COORDINATOR: TRINITY COLLEGE DUBLIN

PARTNERS: KLM ROYAL DUTCH AIRLINES

BAE SYSTEMS (OPERATIONS) LIMITED

DEDALE S.A.

FLS AEROSPACE (IRL) LIMITED

SABENA TECHNICS

STICHTING NATIONAAL LUCHT-EN RUIMTEVAARTLABORATORIUM

JOINT RESEARCH CENTREUNIVESITY OF LA LAGUNA

DUBLIN CITY UNIVERSITY

THALES

ADRIA

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ADAMS 2 AIMADAMS 2 AIM: Define a systematic approach to integrate human factors requirementshuman factors requirements

and operational processes to develop innovative command control systems for transport operators

HF Activity Key Objectives:

•Development of a comprehensive approach to collect and manage information concerning safety and reliability events in the aviation maintenance environment

•Development of a Safety/Human Hazard Analysis focused on maintainability

•Development of a methodology and tool for organisational learning from incidents and events

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Human Hazard Analysis & Error Management StrategyHuman Hazard Analysis & Error Management Strategy

HHA

EDITOR

PAGE

User Name 10.03 AM

HOME > HHA

SAVESAVE CANCELCANCEL

RECORD DATAThe Fields depend on the

particular element selected

HOMEHOMEHELPHELP LOG OFFLOG OFFPREFERENCESPREFERENCESHHAHHA EMSEMS

HHA Interface

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Urban Guided Transport Management System

COMPETITIVE and SUSTAINABLE GROWTH PROGRAMME GRD1-2000-30090

Public Transport Operators: RATP, METRO de MADRID, METROPOLITANO LISBOA, BVG, LONDON UNDERGROUND

PARTNERSHIP:

Suppliers: BOMBARDIER, ALCATEL, ALSTOM, ANSALDO CSEE, DIMETRONIC INVENSYS, TS RA SIEMENS, STSResearch and technology laboratories: INRETS, JRC, TUD, UCL, UVAL

PROJECT START:MARCH 2002PROJECT END: MARCH 2004

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UGTMS AIMUGTMS AIM: Integrating technical systems and operational processes to develop innovative

command control systems for transport operators

HF Activity Key Objective:

At the moment: NO SPECIFIC REGULATION FOR URBAN

RAILWAY SYSTEM AT EUROPEAN LEVEL

•Production of guidelines on the way to use existing and new safety concepts

•Assessment of Functional Requirements Specification (FRS) for guided transport management systems

Directive 2001/16/EC on interoperability of the trans-European conventional rail system (19 March 2001)

Directive 2001/16/EC on interoperability of the trans-European conventional rail system (19 March 2001)

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EUROPEAN COMMISSION - JOINT RESEARCH CENTREInstitute for the Protection and Security of the CitizenHazard Assessment UnitCOMPETITIVE and SUSTAINABLE GROWTH

PROGRAMME GRD1-2000-26801

ENHANCED HUMAN MACHINE INTERFACE FOR ON VEHICLE INTEGRATED DRIVING SUPPORT SYSTEM

PROJECT START:MARCH 2001PROJECT END: MARCH 2004

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EUCLIDE AIMS:EUCLIDE AIMS: • development of a driver support system for driver’s lack of obstacles perception, merging the functionality of two sensors (far infrared and radar);• development of an HMI addressing the most efficient use of warning signals to support thee driver (visual and acoustic)HF Activity Key Objective:

Define the Experimental Plan and performance of the on-road human factors tests.

The European Commission White Paper plans to reduce road fatalities from 41000 each year

to 18000 by 2010

The European Commission White Paper plans to reduce road fatalities from 41000 each year

to 18000 by 2010

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Previous activities:Previous activities:

On-going activity:On-going activity:

• User needs analysis;

• Pilot Plan Design;

• European Road accidents problem evaluation.

• On-road HF tests (JRC leader)

TESTS AIMS: usability evaluation with real users

assessment of impact on road safety

TESTS SITES: 1. Sweden

2. Italy

TESTS SCENARIOS:DAY TIME Day; Night

WEATHER Good weather; bad weather

OBSTACLES

Pedestrian; animals; vehicles; fixed

TRAFFIC High; low

ROAD TYPE

Highway; Extra-urban; Urban; Rural

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Volvo Technology Corporation

BMW Group Forschung und Technik GmbH

DaimlerChrysler AG

Ford-Werke AG

Adam Opel AG

Peugeot Citroën Automobiles

Renault Recherche Innvation

Centro Ricerche de Fiat

Seat Centro Técnico

Robert Bosch GmbH

Johnson Controls GmbH

Siemens VDO Automotive SAS

European Commission Joint Research Centre

Institut National de Recherche sur les Transports et leur Sécurité

Netherlands Organisation for Applied Scientific Research (TNO)

Institute of Communications and Computer Systems

Federal Highway Institute

Centre for Automotive Research and Development

University of Stuttgart

Swedish National Road and Transport Research Institute

VTT Technical Research Centre of Finland

Centre for Research and Technology – Hellas

University of Leeds

Linköping University

Università degli Studi di Genova – Dipartimento di Ingegneria Biofisica ed Elletronica

European Road Transport Telematics Implementation Co-ordination Organisation S.C.R.L

Motorola Limited

KITE Solutions

48/22


AIDE AIMS:AIDE AIMS:

• generate the knowledge and develop methodologies and human-machine interface technologies required for safe and efficient integration of ADAS, IVIS and nomad devices into the driving environment

Sub projects:

(SP1): Modelling and simulation of behavioural effects of ADAS and IVIS

(SP2): Evaluation and Assessment Methodology

(SP3): Design and Development, of an Adaptive Integrated Driver-vehicle Interface

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